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Attachment 2 Incident Investigation/ Near-Miss Investigation .Report Date of Incident' ❑ Patahty ❑ Industrial Non-Recordable ❑ Spill/Leak ❑ Genual Liabihty [] Lost Workday ❑ Non-Industrial ❑ Product Integrity ❑ Criminal Activity ❑ LW Restricted Duty ❑ Off-the-Job Injury ❑ Equipment ❑ Notice of Violation ❑ OSHA Medical or Illness w/o LW ❑ MVA ❑ Business Interruption ❑ Near Miss ❑ Fast Aid ❑ Fire (rO BE COMPLETED BY HR) Tlus repots must be completed by the employee's supervisor or Site Health and Safety Officer immediately upon learning of the incident The completed report must be reviewed and signed by the Principal-In-Charge and e-mailed or faxed to the Vice President of Human Resources, Corporate Health and Safety and the Health&Safety Coordinator within 24 hours of the incident,even if employee is not available to review and sign Employee or employee's doctor must submit a copy of the doctor's report to Human Resources within 24 hours of the initial exam and any subsequent exams Phone 619-718-9429,Fax 619-296-2006,&Marl mhams @secor com. Company Name .*ork Location Address where incident occurred Project Name SSN Birthdate loyment Status ❑ Full I~i>Re ❑ Part-Lyme ❑ HourIy-As-Needed Haw Fong in present job? r.'INJURY Oft 11-1-NESS INFO Where did incident/near cuss occur? (number,street,city,state,zip) County On Employer's premises? ❑ Yes ❑ No Specific activity the employee was engaged in when the incident/near miss occurred All equipment,materials,or chemicals the employee was using when the incident/near miss occurred(e g,the machine employee struck against or which struck employee,the vapor inhaled or material swallowed,what the employee was lifting,pulling,etc) Describe the specific injury or illness(e g,cut,strain,fracture,skm rash,etc} lady part(s)affected(e g,back,left wast,right eye,etc) Name and address of Health Care Provider(e g,physician or chmc) Phone No N hospitaltzed,name and address of hospital Phone No Pate of mjury or onset of illness(MM/DD/YYYY) / / Time of event or exposure ❑ AM ❑ PM cmc employee began wank ❑ AM [I FM Did employee Iose at least one full shift's work? ❑ No ❑ Yes,1st date absent(MM/DD1YYYY) I I Has employee retumed to work? ❑Regular work ❑ Restricted work ❑ No,still off work ❑ Yes,date returned(MM/DD/YYYY} / ! Ioyee die? ❑ No ❑ Yes,date(MM/DD/YY `Y) employer notified of incident/near muss (NEWDD/YYYY) To whom reported Other workers inlured/made ill in this event? ❑ Yes ❑ No SECOR International Incorporated 16 HASP geoprobe